Advanced Topic: Avoiding Aortic Valve Stenosis



Avoiding Aortic Valve Stenosis


migraine These comments are based on my 25 years of cardiology practice but remain formally unpublished, so don’t expect John Q. Cardiologist to confirm these observations. But I saw this pattern over and over again and thought that, until this gets formally published, it is worth knowing about.




Overview

I began adding vitamin D supplementation to my patients’ regimens for its effects in improving insulin resistance, reducing blood sugar, increasing bone density, preventing winter “blues” and other benefits around 10 years ago. I advised people across the board of health conditions: people with coronary disease, lipid (“cholesterol”) abnormalities, cardiomyopathies (diseases of the heart muscle), and heart valve disease. Aortic valve disease, in particular, is among the commonest forms of heart valve disease, affecting around 3-4% of people over 65 years old. It’s not an easy diagnosis to deal with as it unavoidably leads to open-heart surgical aortic valve replacement (though transcutaneous procedures are now gaining ground, also, but still a major procedure).

The aortic valve opens and closes with each heart beat, opening when the main heart muscle, or left ventricle, ejects its substantial blood volume upwards to the aorta, carotid arteries, subclavian arteries, down the descending aorta and to the abdomen, pelvis, and legs. The aortic valve therefore endures high pressure flow, working tirelessly day and night, at both low and high heart rates, with each and every heart beat. By age 60, your heart has been beating and aortic valve opening and closing nearly two billion times—quite a feat for this biological mechanism.

When viewed end on, the normal aortic valve looks like a pie cut in three pieces with each “slice” moving up and down to allow valve opening and closure. While most people are born with a three-slice valve, some people are born with a valve that is divided into only two pieces, a so-called “bicuspid” aortic valve, a valve that does not endure the high-pressure work as well. But I’m specifically focusing on people with valves that have the normal three “slices” or leaflets, I.e., a tri-leaflet valve.

Around 3-4% of the population over age 65 develop progressive stiffness, calcium accumulation, and leaflet adhesions over time that progressively narrow the aortic valve orifice. Typically, someone has a murmur detected on a physical examination, then confirmed by echocardiogram (ultrasound), an easy and precise method to determine the severity of valve stiffness. The severity of aortic valve dysfunction, or stenosis (reduction in valve area opening), is quantified as the maximum area of valve opening in square centimeters. Normal valve area viewed end-on is around 3.0 square centimeters. When a murmur is detected, it is common to have aortic valve areas in the neighborhood of 1.6 or 1.8 square centimeters measured. If no symptoms are present (no chest pain with exertion, no lightheadedness with exertion, or heart failure), echocardiograms are repeated around once per year to track the progression that typically drops by 0.1-0.2 square centimeters per year. A starting value of, say, 1.6 square centimeters leads to 1.4, 1.2, 1.0, 0.8 over ensuing years. Most people develop symptoms around 0.8-1.0 square centimeters. That is when surgical replacement of the valve is planned, as death from valve disease typically occurs only 2-3 years after the appearance of symptoms.

No drug can stop this progression. Statin drugs have been studied in clinical trials (of course) and yielded no impact on the rate of progression. And workaday cardiologists know that aortic valve stenosis is a relentlessly progressive condition that you can do nothing about until surgical replacement . . .

So that’s why I was so surprised when, upon adding vitamin D sufficient to achieve a 25-hydroxy vitamin D blood level of 60-70 ng/ml, I witnessed a complete halt to the expected progression of aortic valve areas in the majority of people with aortic valve stenosis. If I met someone with an aortic valve area of 1.6 square centimeters, a year later it was 1.6, another year later 1.6, another year later 1.6 and onwards. As incredible as it sounds, I even witnessed a handful of people increase their aortic valve area (which is believed to be impossible). I met a dentist, for instance, who survived a heart attack, received a stent at a distant local hospital but, oddly, nobody noticed the huge murmur he had. I obtained an echocardiogram: aortic valve area 1.8 square centimeters. I advised him that surgical aortic valve replacement would likely be necessary in about 5-6 years, given the expected rate of progression. I advised him to start the usual components of the Undoctored program such as omega-3 fatty acids at a truly therapeutic dose, iodine/thyroid optimization, managed his lipoprotein(a) genetic variant, advised wheat/grain avoidance to eliminate small LDL particles, etc. and advised 10,000 units of oil-based gelcap vitamin D, a dose that proved sufficient by 25-hydroxy vitamin D level 6 months later. (Another interesting twist: People with aortic valve stenosis typically also require higher doses of vitamin D to achieve our target level. While most people achieve a 25-hydroxy vitamin D level of 60-70 ng/ml with a dose of 5000-6000 units per day, most people with aortic valve stenosis require 10,000-14,000 units per day, perhaps part of their unique VDR genetic profile, discussed below.) A routine follow-up echocardiogram one year later showed an aortic valve area of 2.3 square centimeters—regression. Not regression all the way back to normal, but partial regression. I asked the echocardiogram technician to show me live images of the valve to make certain no mistakes had been made. Lo and behold, one of the aortic valve leaflets, previously “frozen” because it had become adherent to its neighbor leaflet, was now freed, opening and closing freely and the aortic valve area had indeed increased, also confirmed by the reduction in blood flow velocity through the larger valve orifice.

It became clear that the majority of people (about 50 out of 60) with trileaflet aortic valve stenosis simply stopped getting worse, while a minority regressed and another minority continued to progress to need aortic valve replacement. As this was a preliminary observation, it is not clear why such variation in response to vitamin D develops, but it is likely that differences in vitamin D receptors, VDRs, were responsible. In other words, while some people develop type 1 diabetes with vitamin D deficiency, others develop osteopenia/osteoporosis, others develop cancer, and some develop aortic valve stenosis, all dependent on VDR genetics.

A few additional issues:
  • Adding vitamin K2, even at presumably therapeutic doses of 180 mcg per day of the MK-7 or 4000 mcg per day of the MK-4 forms, did not improve the response when added to vitamin D. This is consistent with the observation that adding K2 also had no impact on the progression/regression of coronary calcium scores, while vitamin D exerted a major impact. However, it is difficult to reconcile the failure of K2 to add to effects on the aortic valve when people prescribed warfarin (that blocks K1 and K2 metabolism) develop accelerated aortic valve calcium accumulation. Note, of course, that, given the benign nature of vitamin K1/K2 supplementation, there is no harm in adding K2 to vitamin D.
  • These observations were made with cessation of all oral calcium supplementation to stop any theoretical contribution of excess calcium to aortic valve calcium deposition.

The key here, of course, is not to wait until you have a murmur detected or aortic valve stenosis identified by echocardiogram, but to begin efforts like vitamin D restoration early in life and to achieve a 25-hydroxy vitamin D level in our presumptive therapeutic range. You may thereby prevent the later development of aortic valve stenosis, providing yet another way to deprive the medical system of their desire for high-ticket procedures. Because we know that vitamin D supplementation is not only benign, but yields numerous substantial health benefits, I know of no downside to starting as early in life as possible. These observations were casual and not published, but were so consistent over more than 50 patients that I am confident that the majority of people who engage in vitamin D restoration to these target blood levels will obtain similar benefits. At some point, we will need to have these observations formally explored via a clinical trial.